Original research BMJ Glob Health: first published as 10.1136/bmjgh-2020-003429 on 3 December 2020. Downloaded from Surgical site infection after gastrointestinal surgery in children: an international, multicentre, prospective cohort study GlobalSurg Collaborative To cite: GlobalSurg ABSTRACT Key questions Collaborative. Surgical site Introduction Surgical site infection (SSI) is one of the infection after gastrointestinal most common healthcare- associated infections (HAIs). What is already known? surgery in children: an However, there is a lack of data available about SSI in international, multicentre, There is a lack of data describing the incidence and children worldwide, especially from low- income and ► prospective cohort risk factors for surgical site infection (SSI) in chil- middle- income countries. This study aimed to estimate the study. BMJ Global Health dren. This paucity of data is particularly prevalent incidence of SSI in children and associations between SSI 2020;5:e003429. doi:10.1136/ in low- middle income populations (LMICs), who are and morbidity across human development settings. bmjgh-2020-003429 likely to be affected most by SSI, yet no prospective, Methods A multicentre, international, prospective, multicentric comparative data exist. Handling editor Senjuti Saha validated cohort study of children aged under 16 years undergoing clean- contaminated, contaminated or dirty What are the new findings? ► Additional material is gastrointestinal surgery. Any hospital in the world providing Children undergoing gastrointestinal surgery in low- published online only. To view, ► paediatric surgery was eligible to contribute data between please visit the journal online middle development countries are significantly more (http:// dx. doi. org/ 10. 1136/ January and July 2016. The primary outcome was the likely to have SSIs after surgery than their counter- bmjgh- 2020- 003429). incidence of SSI by 30 days. Relationships between parts in high income settings. Use of laparoscopy explanatory variables and SSI were examined using was associated with lower odds of SSI. multilevel logistic regression. Countries were stratified Received 13 July 2020 into high development, middle development and low What do the new findings imply? Revised 19 August 2020 development groups using the United Nations Human ► SSI is common in LMICs, occurring in up to a quarter Accepted 22 August 2020 Development Index (HDI). of operations. Our data should be used as a founda- Results Of 1159 children across 181 hospitals in 51 tion to inform clinical trials and to build initiatives to http://gh.bmj.com/ countries, 523 (45·1%) children were from high HDI, 397 reduce this. SSI is associated with poorer outcomes (34·2%) from middle HDI and 239 (20·6%) from low HDI and longer lengths of stay, which can be devastating countries. The 30- day SSI rate was 6.3% (33/523) in high for a family and for children’s well- being. HDI, 12·8% (51/397) in middle HDI and 24·7% (59/239) in low HDI countries. SSI was associated with higher incidence of 30- day mortality, intervention, organ- space from school and lost working days by parents infection and other HAIs, with the highest rates seen in low to assist children, putting family units at risk on September 27, 2021 by guest. Protected copyright. HDI countries. Median length of stay in patients who had of catastrophic healthcare expenditure.1 2 an SSI was longer (7.0 days), compared with 3.0 days in Furthermore, the societal burdens of SSI in patients who did not have an SSI. Use of laparoscopy was associated with significantly lower SSI rates, even after terms of healthcare costs and the require- accounting for HDI. ments for antibiotic therapy have important Conclusion The odds of SSI in children is nearly four consequences for affordability, antibiotic times greater in low HDI compared with high HDI countries. resistance and health system capacity. Policies to reduce SSI should be prioritised as part of the Previous studies have predominately come © Author(s) (or their wider global agenda. from single hospitals, been heterogeneous employer(s)) 2020. Re- use permitted under CC BY. in patient and procedure inclusion, and Published by BMJ. been inconsistent in the different diagnostic 3–5 Department of Clinical Surgery, criteria for SSI. Furthermore, these studies University of Edinburgh INTRODUCTION are often limited in geographical scope, with Division of Clinical and Surgical Surgical site infection (SSI) is one of the most one systematic review and meta- analysis of HAI Sciences, Edinburgh, UK common healthcare- associated infections identifying only three studies in paediatric 6 Correspondence to (HAIs) following gastrointestinal surgery. patients in low- middle income countries. Ewen M Harrison; In children, SSI has important social and In these settings, SSI incidence is markedly ewen. harrison@ ed. ac. uk economic consequences, leading to time away higher than in high income countries.7 GlobalSurg Collaborative. BMJ Global Health 2020;5:e003429. doi:10.1136/bmjgh-2020-003429 1 BMJ Global Health BMJ Glob Health: first published as 10.1136/bmjgh-2020-003429 on 3 December 2020. Downloaded from The primary aim of this study was to determine the or HIV), disease variables (pathology) and operative vari- worldwide SSI rate following gastrointestinal surgery in ables (urgency, procedure start time, operative approach, children while the secondary aim was to identify asso- WHO surgical safety checklist use, antibiotic prophy- ciations between SSI and morbidity among children by laxis and intraoperative contamination). Intraoperative country development, according to the United Nation’s contamination was measured by the operating surgeon Human Development Index (HDI). and defined as follows; clean-contaminated (an incision through the respiratory, alimentary or genitourinary tract under controlled conditions with no direct contam- METHODS ination encountered), contaminated (an operation Patient public involvement where there is major break in sterile technique or gross Patients and the public were involved in design and spillage from the gastrointestinal tract, or an incision dissemination of this study, including representation where acute non- purulent inflammation is encountered from patients in low HDI countries. We included patients or where procedures involve traumatic wounds that have in the conception, design and steering of the overall been open for between 12 hours and 24 hours) and dirty GlobalSurg 2 Study and GlobalSurg collaborative. (an incision undertaken where viscera are perforated, where acute inflammation or necrosis is encountered, or Study design where there is delayed operation on traumatic wounds) This international, multicentre, prospective cohort study procedures. was performed according to a published protocol and was Within each team, quality assurance was guaranteed registered on ClinicalTrials. gov (NCT02662231).8 Inves- by at least one consultant or attending-level surgeon. tigators were recruited via the international GlobalSurg Data were recorded prospectively and stored on a secure, collaborative research network, surgical associations, internet- based, user- encrypted platform (REDCap).13 training colleges, social media and personal contacts. The structure of surgical collaborative research methodology Primary outcome has been described in detail previously.9 Briefly, small The primary outcome measure was the 30-day post- teams of local investigators collected data on prospec- operative SSI rate according to the Centre for Disease tively determined items, coordinated by regional and Control and Prevention criteria for SSI.14 SSI rates were national lead investigators, across short time windows, measured at 30 days following surgery either in person with pooled analysis by a central steering committee. A or by computer record/chart review. When 30-day parallel analysis which also included adults (>16 years) follow- up was not possible, SSI was measured at the point has already been published elsewhere.10 of discharge. Surgical teams were encouraged to assess This study is reported according to the STrengthening patients at 30 days (either in- person or via telephone). the Reporting of OBservational studies in Epidemiology Secondary outcome measures included the 30- day post- guidelines and the Statistical Analyses and Methods in operative mortality rate, reintervention rate, rate of the Published Literature.11 12 wound organ- space inefction, rate of other HAIs and http://gh.bmj.com/ Any hospital in the world performing gastrointestinal length of stay. Data were also collected on antimicrobial surgery on children was eligible to participate in this therapy and microbiology culture from patients with study. Hospitals could be secondary or tertiary health- SSI. Antibiotic resistance was defined as resistance in the care facilities. Our network includes both small commu- species which was cultured to the antibiotic administered nity hospitals and large tertiary referral hospitals. There for prophylaxis. was no minimum case-volume, or centre- specific require- on September 27, 2021 by guest. Protected copyright. ments to take part. Participating clinicians registered Statistical analysis online and had to successfully pass a mandatory online As described in the protocol, countries were stratified training module to standardise data collection. Inves- into tertiles of development using the United Nations tigators included consecutive patients over a 2-week HDI. This metric is